Employee Health Policy & Waiver

EMPLOYEE HEALTH POLICY & WAIVER

Employer Name:     Employee Name:     Policy Effective Date:

Personal Information

Position Information

Employment History

Education

References

Employee Health Policy

Purpose: The Employer maintains this Employee Health Policy to protect workplace safety, reduce the transmission of communicable diseases, and ensure consistent procedures for reporting, testing, exclusion, return-to-work clearance, and reasonable accommodation. This Policy applies to all employees and related on-site personnel.

Reporting Illness: Employees must immediately notify their manager and Human Resources if they are diagnosed with, or exhibit symptoms of, a communicable disease that may present a risk to coworkers. Notification must occur no later than the next scheduled work shift unless extenuating circumstances exist.

Medical Screening and Testing: The Employer may require medical screening, testing, or documentation of fitness for duty when necessary to prevent a direct threat to workplace safety. Employee consents to provide medical documentation from a licensed provider when requested for return-to-work determinations.

Vaccination and Immunization: The Employer may, consistent with applicable law, require proof of vaccination or immunization status for certain roles or during specific public health conditions. Employees must indicate vaccination status below and, if declining required vaccination, may be required to comply with alternative mitigation measures.

Fully vaccinated Partially vaccinated Decline to state / Declined vaccination

Confidentiality of Medical Records: Medical information obtained under this Policy will be maintained separately from personnel records and disclosed only to those with a legitimate need to know for workplace safety, accommodation decisions, or as required by law. The Employer will use and disclose employee medical information in a limited manner consistent with applicable privacy protections.

Reasonable Accommodation: Employees who request an accommodation for a medical condition, pregnancy, or disability should promptly notify Human Resources. The Employer will engage in an interactive process to consider reasonable accommodations, documentation requirements, and alternatives that permit continued employment while protecting workplace safety.

Leave and Compensation: Sick leave, family leave, and other paid or unpaid leave provisions will be administered in accordance with existing company policies and applicable law. Documentation may be required for extended absences.

Waiver, Release of Liability, and Assumption of Risk

Assumption of Risk: By signing below, the Employee acknowledges that work activities may involve exposure to contagious illness and that the Employer cannot eliminate all risk. The Employee accepts and assumes such risks to the fullest extent permitted by law.

Release: Except to the extent prohibited by law, the Employee releases the Employer, its officers, directors, employees, agents, and representatives from claims arising from illness or injury potentially related to workplace exposure, provided the Employer has acted without gross negligence or willful misconduct. This release does not waive statutory rights that cannot be released by private agreement.

Limited Remedies: Employee acknowledges that any disputes arising under this Policy will be governed by the Employer's dispute resolution procedures where applicable, and that remedies are subject to applicable law and public policy limitations.

Authorization & Consent

Authorization to Obtain Medical Information: Employee authorizes any healthcare provider to disclose relevant medical information to the Employer for the purposes of assessing fitness for duty, reasonable accommodation, or return-to-work clearance.

Background Checks and Employment Verification: Employee authorizes the Employer to contact prior employers and references provided in this form to verify employment history and to conduct background checks where permitted by law. Consent to such checks is indicated below.

I consent to employment verification and background checks as required by the Employer.

Legal Disclosures

At-Will Employment: Nothing in this Health Policy & Waiver alters the at-will nature of employment unless expressly provided in a separate written agreement signed by authorized representatives of the Employer and the Employee.

Equal Opportunity: The Employer provides equal employment opportunities without regard to protected characteristics. Health-related decisions, including reasonable accommodations, will be made consistent with nondiscrimination obligations.

Employee Certification and Acknowledgment

I certify that all information I have provided in this document is true and complete to the best of my knowledge. I understand and agree to follow the Employer's health and safety protocols. I further acknowledge that failure to follow required protocols or to provide accurate information may result in disciplinary action up to and including termination.

I certify that the information provided on this form is true and complete and that I have read and understand the Employee Health Policy & Waiver.

I authorize the release of medical information to the Employer as described above and consent to necessary screenings consistent with this Policy.

Supplemental Notes

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